As a practicing pediatrician I have been seeing more patients with symptoms of reflux, and more parents who are concerned about the implications of this condition.

Gastroesophageal reflux (GER) does seem to be more common in children now than in previous generations, but there's also another reason we hear about it more often: pediatricians and parents are more aware of it.

Dr. Tom Lin, a pediatric gastroenterologist at Duke, explains what reflux is and what can be done about it.

-- Dennis Clements, MD, PhD, MPH

Tom K. Lin, MD

Is gastroesophageal reflux (GER) becoming more common or are we becoming better at diagnosing it? The short answer is probably both.

Technological advances in medicine are ever-growing -- what were merely thoughts and fledgling ideas 20 to 30 years ago are today’s reality. Not only are we able to peer into the gastrointestinal tract (called endoscopy) with detail as crisp as high-definition television, but current medicine also allows us to sample tissue and directly treat diseases of the intestinal tract deep within the small bowel in a less invasive manner than previously believed possible without so much as leaving a scar.

Such advances have led to the identification of milder cases of GER and unusual, atypical presentations of this common disorder. Hence, there are a greater number of diagnoses that would have otherwise gone unrecognized.

Signs and Symptoms of GER

Factors outside the influence of medicine have also lead to a heightened awareness resulting in a rise in the diagnosis of GER. Pervasive media coverage and pharmaceutical advertising have elevated the general public’s knowledge and understanding of GER.

It’s good for parents to learn and be able to recognize the early signs of the possible health complications related to GER. However, too often parents are led to believe that infants and children are too young to have this condition, when a more aggressive evaluation and treatment plan may be warranted.

The idea of a child having regurgitation or “heartburn” is disconcerting to parents. They may worry that it will lead to internal intestinal damage, with a worst case scenario resulting in a pre-cancerous lesion referred to as Barrett’s esophagus. This misconception is no fault of the parents, but parental anxiety can lead to unnecessary testing with its own set of potential risks and complications.

It is important for the medical professional to dispel the myths and misconceptions of GER, while also educating parents to recognize “red flag” signs and symptoms including when to seek the evaluation from a health care professional.

How can parents protect their child from unnecessary medical evaluations and tests while feeling confident their child does not have a serious medical condition? The old adage that knowledge is power applies here. Knowing the facts about GER and being able to recognize warning signs is the key to keeping your child happy and healthy.

Fact one is that most children do not need to undergo formal, definitive testing to be diagnosed with GER. Today, it is common and accepted medical practice to presumptively treat infants and children for possible GER if symptoms are compatible in the absence of signs/symptoms suggestive of a more severe, complicating disease or of an alternative diagnosis.

Performance of diagnostic studies are most often reserved for cases of persistent or unresponsive symptoms despite the use of anti-reflux medicines, symptom recurrence following the discontinuation of the medicines, or suspicion for another disease process.

To help demystify GER, it is important to address the facts about GER. GER is a normal physiologic occurrence in infants (particularly those born prematurely), children and adults. It is a common occurrence during infancy with approximately 95 percent of infants having “outgrown” it by 12 months of age.

Most GER occurs when the lower muscle controlling the opening between the esophagus and stomach opens intermittently, referred to as transient lower esophageal sphincter relaxation or TLESR for short, which occurs at a greater frequency in infants than it does in children.

When this occurs, it allows an open pathway for stomach contents, usually food and formula, to regurgitate through the mouth and at times through an infant’s nose because of the normal anatomical connection between the oral and nasopharynx (the throat cavity and nasal passages).

For older children, dietary factors may play a role in the development of symptomatic GER. Being overweight or obese can also contribute to the severity of a child’s GER, with weight loss being just one of a number of conservative measures that can help manage a child’s symptoms.

Treatments for GER

Often conservative measures may be all that is needed to help alleviate the symptoms of GER in infant and children. This includes:

• Upright positioning after feedings
• Avoidance of overfeeding
• Thickened formula feedings
• Formula change (possible milk protein intolerance)

Additional factors for older children:

• Food eliminations (e.g., caffeine)
• Weight loss/reduction (in children who are overweight or obese)
• Avoidance of late-night eating

Specific abnormal symptoms or their persistent may be a sign of a more serious underlying health condition. The following are what parents should watch for and discuss further with their child’s health care provider:

• Rectal bleeding
• Persistent diarrhea
• Vomiting blood
• Poor growth or weight gain
• Weight loss
• Persistent poor feeding and oral intake
• Prolonged period of feeding refusal, difficulty in swallowing or pain with swallowing
• No breathing (apnea) or difficulty in breathing
• Excessive or forceful vomiting in early infancy
• Unusual changes in behavior, energy level, alertness
• Chronic cough or recurrent pneumonia
• Excessive, prolonged periods of crying
• Chronic vomiting or regurgitation

Today, physicians are more equipped than ever to diagnose, manage and treat uncomplicated and complicated GER in children. Despite these current capabilities, we still do not possess all of the answers. Until that time comes, there needs to be continued efforts to maintain the delicate balance between over and under diagnosing GER.

-- Tom K. Lin, MD, is a gastroenterologist in the Duke Department of Pediatrics.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.